Lesions causing a mass in the medial canthus of the orbit: CT and MR features

Squamous Cell Carcinoma of the Lacrimal Drainage System: Case Report and Literature Review

Aims and background

Epithelial malignant tumors of the lacrimal drainage system are rare. The most prevalent type is squamous cell carcinoma. These tumors generally present with aspecific symptoms suggestive of chronic dacryocystitis, with the result that diagnosis and treatment are often delayed.

Methods and study design

We present the case of a patient with a squamous cell carcinoma of the lacrimal ducts and discuss the clinical and pathological features of these neoplasms, together with diagnostic and therapeutic strategies according to the data available in the literature.

Results and conclusion

The diagnostic and therapeutic approach to this kind of rare tumors has to be planned carefully. Radiographic examination of all masses arising in the medial canthus is essential. Dacryocystography allows the identification of space-occupying tumors in the lacrimal sac. Computed tomography and magnetic resonance imaging provide the most useful information about the extent of the neoplasm and its relationship with surrounding bone structures and soft tissues. Histological examination of a biopsy sample obtained by standard dacryocystectomy is essential to confirm the diagnosis. The treatment of choice is primarily surgical, consisting of complete resection with long-term follow-up. A number of surgical procedures have been described, which are more or less aggressive depending on the extension of the tumor. Radiotherapy is indicated when bone or lymphatic invasion is evident, and when neoplastic cells are present in the resection margins. Radiotherapy alone is not considered a treatment of choice, but only a palliative option in selected cases. The follow-up data available in the literature are incomplete. In most of the literature reports, relapse occurs in 50% of patients within 5 years.

Orbital Cyst of Lacrimal Sac Derivation

Orbital cyst from lacrimal sac epithelium is rare and thought to originate from diverticulum of the lacrimal sac. The cyst may have direct communication with the sac, or the two structures may be anatomically separate. Since these lesions most commonly present as a medial canthal mass, the differential diagnosis should include other disorders that may cause a mass in this region. A 42 year old woman presented with a two-year history of a mass in the right medial canthal region. Nasolacrimal system was patent on irrigation. Sophisticated radiological investigation utilizing dacryocystography and computed tomography combined with dacryocystography accurately localized the lesion and demonstrated its relationship to the nasolacrimal system. This tremendously facilitated surgical removal. The lesion was excised completely via anterior orbitotomy and submitted for histopathologic examination. Haematoxylin-eosin stains revealed a cystic cavity lined by pseudostratified columnar and cuboidal epithelium with interspersed goblet cells consistent with a cyst derived from lacrimal sac epithelium, located separately, but in close proximity to the lacrimal sac. The Authors present a patient with a mass in the righ medial canthal area histologically diagnosed as an orbital cyst of lacrimal sac epithelium derivation. Sophisticated radiological lacrimal investigation helps in detection, localization and in planning surgery.

Medial Orbital Epidermoid Cyst

Dermoid and epidermoid cysts are among the most common orbital tumors, comprising 3% to 9% of all orbital masses. We report a rare case of upper medial orbital epidermoid cyst of a 2-year-old patient. The patient was complaining of pain in the right eye and infrequent vomiting. The neurological and radiographic examinations showed no pathological findings, only after CT scan was performed a tumor formation was found. After the extirpation a histological examination was performed proving the diagnosis.

[Lacrimal duct tumors: diagnostic and therapeutic dilemmas]

INTRODUCTION

Fewer than 250 primary tumors of the lacrimal duct have been reported in the international literature. Because their signs and symptoms are nonspecific and usually subclinical, delayed diagnosis is common. Treatment for malignant epithelial tumors is surgical, with or without radiation.

PATIENTS AND METHODS

The present study is a retrospective analysis of five patients with malignant lacrimal duct tumors.

RESULTS

Three patients were diagnosed with carcinoma requiring wide en bloc surgical resection with surgical reconstruction. One underwent adjuvant radiation therapy. Another experienced simultaneous local and lymph node recurrence after 3 years and underwent curative surgery. Two additional patients were diagnosed with diffuse malignant large B-cell non-Hodgkins lymphoma.

DISCUSSION

Early symptoms of lacrimal duct tumors are nonspecific and mimic acute dacryocystitis. Lacrimal system CT, MRI and rhinoscopy may allow for earlier diagnosis. Surgical treatment requires resection with wide margins and reconstruction of the medial canthal region.

CONCLUSION

Only an early diagnosis can reduce the impairment related to surgery and the extent of the required reconstruction, as well as improve survival.

Les tumeurs malignes primitives des voies lacrymales

OBJECTIVES

To assess the clinical characteristics, the workup, therapeutic approach and pathological findings of primitive tumors of the lacrimal sac.

MATERIAL AND METHODS

Three cases were retrospectively reviewed from the database of our ENT department. They were analyzed and compared to cases reported in the literature.

RESULTS

One adenoid cystic carcinoma and two adenocarcinomas were observed, all were adults and the sex ratio was one man for 2 women. Clinically they presented neither significant lacrimal or rhinologic sign. A CT-scan and a MRI were performed along with a physical examination. An entire surgical resection was done with subsequent postoperative radiotherapy. Two patients died, and one is alive, free of disease.

CONCLUSION

Lacrimal tumors should be considered in the differential diagnosis of a banal chronic epiphora. The ENT practitioner must associate this factor to any clinical evaluation. The management of these lesions requires a complete surgical resection, routinely associated with postoperative radiation.

Radiologic Evaluation of Lacrimal and Orbital Disease

This article discusses the evaluation of specific lacrimal disorders and orbital trauma using CT, MRI, and other radiologic techniques.

Rethinking orbital imaging establishing guidelines for interpreting orbital imaging studies and evaluating their predictive value in patients with orbital tumors

PURPOSE

To establish guidelines for interpretation of orbital imaging by magnetic resonance imaging (MRI) and/or computed tomography (CT), and to apply these guidelines and examine their predictive value in 131 patients with biopsy-proven orbital tumors.

DESIGN

Prospective evaluation of imaging studies.

PARTICIPANTS

Imaging studies (CT and/or MRI) from 131 cases with biopsy-proven orbital tumors.

METHODS

Guidelines for reviewing orbital imaging studies (MRI and/or CT) were established based on 5 major characteristics: (1) anatomic location, (2) bone and paranasal sinuses involvement, (3) content, (4) shape, and (5) associated features. In total, 84 features were established by an experienced orbital surgeon and a neuroradiologist. Applying these 84 features, imaging studies of 131 biopsy-proven orbital tumors were evaluated by 3 physicians.

MAIN OUTCOME MEASURES

Imaging features: characteristics, sensitivity, specificity, and positive and negative predictive values in various groups of orbital tumors and kappa values.

RESULTS

One hundred thirty-one cases of biopsy-proven orbital tumors were evaluated. Benign lesions were more likely to be smaller in size, round or oval in shape (29% of all benign tumors, 0% in malignant and inflammatory, P<0.001), and associated with hyperostosis (22% of all benign lesions, P<0.001). They were also more likely to be hyperdense or hypodense on CT imaging (15% and 11%, respectively; P<0.05 in comparison with inflammatory and malignant tumors). Inflammatory processes showed panorbital involvement (23% vs. 3%, and 0% in benign and malignant tumors, respectively; P<0.001). Orbital fat involvement and fat stranding were noticed only in inflammatory lesions (19% and 16%, respectively; P<0.001). None of the features occurred only in malignant tumors, but they tend to involve the anterior orbit more commonly (54% vs. 20%, and 29% in benign and malignant; P = 0.002), and were more likely to show bone erosion (31% vs. 6%, and 16% in benign and inflammatory tumors, respectively; P = 0.004) and molding around orbital structures (29% vs. 3% in benign, and 0% in inflammatory tumors, respectively; P<0.001). Features such as panorbital involvement, orbital fat, frontal sinus opacity, molding around orbital structures, perineural involvement, and fat stranding had specificity of 97% to 100%, but low sensitivity.

CONCLUSIONS

Guidelines for analysis of orbital imaging studies (CT or MRI) are suggested. Based on these guidelines several imaging features showed significantly different occurrences in benign, malignant, and inflammatory processes; although this can help in differential diagnosis, tissue diagnosis may still be required.

Computed tomography dacryocystography evaluation of the nasolacrimal apparatus

Computed tomography-dacryocystography (CT-DCG) was used to evaluate the nasolacrimal system in four patients (three dogs and one horse) that were admitted for evaluation of chronic epiphora, facial swelling, or facial trauma. The four patients are reviewed and the technique for performing CT-DCG is described. Additionally, the indications for this procedure are discussed. CT-DCG is advantageous because cross-sectional imaging provides superior resolution of the nasolacrimal apparatus and the relatively long, small-diameter, bony nasolacrimal canal in most veterinary patients.

CT evaluation of nasolacrimal relapse of nasopharyngeal carcinoma

AIM

The aim of the current study was to elucidate the anatomy of the nasolacrimal apparatus using computed tomography (CT), and to investigate the CT findings suggestive of recurrent nasopharyngeal carcinoma (NPC) involving the nasolacrimal apparatus.

MATERIALS AND METHODS

CT images of five patients with clinical or radiological findings suggestive of recurrent NPC who presented with nasolacrimal involvement were reviewed. Involvement of the lacrimal fossa, nasolacrimal canal (NLC), and adjacent anatomic structures including orbit and sinonasal cavities were noted.

RESULTS

CT in all patients demonstrated findings of NLC invasion and ostiomeatal complex obliteration. Four of the five patients showed medial canthal mass or pre-septal thickening, ethmoid bulla opacification and inferior nasal meatal involvement.

CONCLUSION

Knowledge of the anatomy of the nasolacrimal apparatus using CT is critical for evaluating images for tumour recurrence at this site. NLC invasion, a medial canthal mass and pre-septal thickening are important primary indicators for potential involvement of the nasolacrimal apparatus by recurrent NPC. Secondary signs suggesting this distinct form of relapse are obliteration of ostiomeatal channel, ethmoid bulla opacification and inferior nasal meatus involvement.

Computed tomography of orbital dermoids: a 20-year review

AIM

To review the computed tomographic images of orbital dermoid cysts referred to our institution over a 20-year period.

MATERIALS AND METHODS

The CT images of 160 patients with histologically proven orbital dermoid cysts were reviewed and patient demographics and cyst characteristics were recorded.

RESULTS

A total of 160 dermoid cysts were seen, 87 were in male and 73 in female patients with mean ages of 29 and 27 years respectively. The lateral aspect of the orbit was the most common site (69%, 111/160). Eighty-five percent (136/160) had adjacent bone changes, 46% (73/160) were of lower CT attenuation than the water in the vitreous body, 14% (22/160) had calcification, 5% (8/160) had fluid levels, 73% (117/160) had a visible wall and 80% (129/160) had no soft tissue present outside the cyst.

CONCLUSION

Our study shows that orbital dermoids are frequently located at the lateral canthus. Bone sparing, calcification, fluid level, no visible wall and no abnormal soft tissue outside the cyst are infrequent. A CT attenuation similar to fat is relatively frequent. Although many lesions are typical, the range of appearances is wide.